The Australian Transport Safety Bureau (ATSB) is Australia's national transport safety investigator. The ATSB's function is to improve safety and public confidence in the aviation, marine and rail modes of transport. The ATSB is Australia's prime agency for the independent investigation of civil aviation, rail and maritime accidents, incidents and safety deficiencies.

Summary

Summary

On 27 August 2008 at 1238 Eastern
Standard Time, a solo student pilot in a Cessna Aircraft Company
A150M aircraft, registered VH-UPY (UPY), and a student pilot and
instructor in a Piper Aircraft Corp PA-28-161 aircraft, registered
VH-CGT (CGT), were flying about 3 km north-west of Moorabbin
Aerodrome, Victoria.

The pilot of UPY conducted a
touch-and-go on runway 31 left (31L) at Moorabbin as CGT was
entering the control zone from the north-west at 1,000 ft above
mean sea level (AMSL) to join the circuit on left downwind for
runway 31L. As CGT approached the circuit pattern, the student
pilot saw UPY, very close and climbing from his left on a collision
course, and took avoiding action. However, the two aircraft
collided, resulting in UPY colliding with terrain and fatal
injuries to the solo student pilot.

In the time leading up to the
collision, the air traffic controller workload had been high and
relevant traffic information was not issued to the pilots in
sufficient time to assist self‑separation. The investigation
identified that the design of the then Moorabbin Aerodrome General
Aviation Aerodrome Procedures (GAAP) airspace did not provide
lateral or vertical separation between traffic flows, and that this
increased the risk of a midair collision. In addition, Airservices
Australia (Airservices) had not acted on a number of internal
recommendations to manage a gradual increase in operations at
Moorabbin.

As a result of this investigation,
Airservices have undertaken a review of their internal processes
for reviewing safety performance. In addition, as a result of a
number of midair collisions in the vicinity of GAAP aerodromes, the
Civil Aviation Safety Authority (CASA) undertook several reviews of
GAAP leading to improved training procedures and, as an interim
measure, restrictions on the number of aircraft in the circuit. On
3 June 2010, CASA implemented Class D airspace procedures at all
GAAP aerodromes throughout Australia.